What is Optimum Foetal Positioning?

'Optimal Foetal Positioning' (OFP) is a theory developed by a midwife, Jean

Sutton, and Pauline Scott, an antenatal teacher, who found that the mother's
position and movement could influence the way her baby lay in the womb in the
final weeks of pregnancy. Many difficult labours result from 'malpresentation',
where the baby's position makes it hard for the head to move through the pelvis, so
changing the way the baby lies could make birth easier for mother and child.

The 'occiput anterior' position is ideal for birth - it means that the baby is lined up
so as to fit through your pelvis as easily as possible. The baby is head down, facing
your back, with his back on one side of the front of your tummy. In this position,
the baby's head is easily 'flexed', ie his chin tucked onto his chest, so that the
smallest part of his head will be applied to the cervix first. The diameter of his
head which has to fit through the pelvis is approximately 9.5 cm, and the
circumference approximately 27.5cm. The position is usually 'Left Occiput
Anterior' or LOA - occasionally the baby may be Right Occiput Anterior or ROA.

The 'occiput posterior' (OP) position is not so good. This means the baby is still
head down, but facing your tummy. Mothers of babies in the 'posterior' position are
more likely to have long and painful labours as the baby usually has to turn all the
way round to facing the back in order to be born. He cannot fully flex his head in
this position, and diameter of his head which has to enter the pelvis is
approximately 11.5cm, circumference 35.5cm.

If your baby is in the occiput posterior position in late pregnancy, he may not
engage (descend into the pelvis) before labour starts. The fact that he doesn't
engage means that it's harder for labour to start naturally, so your baby are more
likely to be 'late'. Braxton-Hicks contractions before labour starts may be
especially painful, with lots of pressure on the bladder, as the baby tries to rotate
while it is entering the pelvis. Be aware that if you accept induction on the basis of
being postdates, and your baby is in a suboptimal position, you may have a tough
haul ahead of you. See "Overdue - but desperate for a homebirth?" for more
discussion of this issue.

The majority of babies who are Occiput Posterior during labour, actually
started off labour in an Occiput Anterior position. According to Gardberg
(1998), who has published a number of studies on posterior presentation, about 2/3
of babies who are 'persistent occiput posterior' start off OA, while 1/3 were OP
when labour started.
 Persistent Occiput Posterior

'Persistent Occiput Posterior' means that the baby is born in the OP position -
otherwise known as "face to pubes". The majority of babies who are OP at some
point in labour, will turn to occiput anterior during the labour and will be born
face-down ("face to bum" if you like!). Gardberg found that 87% of babies who
were OP at the start of labour, rotated to OA to be born.

Posterior presentation is more of a problem for first babies and their mothers than
it is for subsequent births; when a mother has given birth before, there is generally
much more room for maneouvre, so it is easier for the baby to rotate during labour.
It can still be hard work, though, as the story of the birth of Deborah Black's third
baby, Kyle, shows.

Sutton and Scott note that the rate of posterior presentation has increased
drastically in the last few decades, apparently in line with changes in the way
women use their bodies. Sitting in car seats and leaning back on comfortable sofas,
together with less physical work, have combined to produce an increase in
posterior presentations. Paying attention to your posture in the last few weeks of
pregnancy can help to reverse this trend. Since keeping reasonably active in
pregnancy, and practising good posture, isn't going to do anyone any harm, this
theory at least deserves to be considered.

When do you need to start doing something about this?

Recent research has suggested that there may be little point in practising OFP
techniques in late pregnancy as a 'routine intervention', ie as a matter of course -
for instance, if your baby is already occiput anterior. However, if your baby seems
to have settled in an OP position, then it may well be worth putting in some effort
to shift her.

Pay attention to your posture at the time when your baby may be starting to
'engage', which means its head will be descending into the pelvis. This means for
the last six weeks of your first pregnancy, and the last two or three weeks of
subsequent pregnancies. In your second and later pregnancies, the uterus is more
roomy and the baby will not normally start to descend into the pelvis until later,
and often not until labour starts.
 What position is your baby in?
This is important because you need to know when your baby moves into a good
position, so that you can encourage it to stay there! You can learn to tell what
position your baby is in, by asking midwives to show you what to look out for, and
by practising feeling for the baby yourself.

When the baby is anterior, the back feels hard and smooth and rounded on one side
of your tummy, and you will normally feel kicks under your ribs. Your belly
button (umbilicus) will normally poke out, and the area around it will feel firm.
When the baby is posterior, your tummy may look flatter and feel more squashy,
and you may feel arms and legs towards the front, and kicks on the front towards
the middle of your tummy. The area around your belly button may dip in to a
concave, saucer-like shape.

If you feel the baby move, try work out what body part was moving. Remember
that heads feel hard and round, while bottoms feel soft and round! It may take a lot
of concentration and trying to work things out at first, but you soon get the hang of
it. You may find it easier to feel your baby's position if you lie on your back with
your legs stretched flat out.

If your baby is posterior, you may find that you suffer backache during late
pregnancy (of course, many women suffer backache then anyway). You may also
experience long and painful 'practice contractions' as your baby tries to turn around
in order to engage in the pelvis.
 Practical steps to avoid posterior positions
The baby's back is the heaviest side of its body. This means that the back will
naturally gravitate towards the lowest side of the mother's abdomen. So if your
tummy is lower than your back, eg you are sitting on a chair leaning forward, then
the baby's back will tend to swing towards your tummy. If your back is lower than
your tummy, eg you are lying on your back or leaning back in an armchair, then
the baby's back may swing towards your back.

For more detailed discussions of positioning, some good diagrams, and lots of tips
for turning babies, please see the sources listed at the end of this article.

Avoid positions which encourage your baby to face your tummy. The main culprits
are said to be lolling back in armchairs, sitting in car seats where you are leaning
back, or anything where your knees are higher than your pelvis.

The best way to do this is to spend lots of time kneeling upright, or sitting upright,
or on hands and knees. When you sit on a chair, make sure your knees are lower
than your pelvis, and your trunk should be tilted slightly forwards.

 Watch TV while kneeling on the floor, over a beanbag or cushions, or sit on

a dining chair. Try sitting on a dining chair facing (leaning on) the back as
well.

 Use yoga positions while resting, reading or watching TV - for example,

tailor pose (sitting with your back upright and soles of the feet together,
knees out to the sides)[3]

 Sit on a wedge cushion in the car, so that your pelvis is tilted forwards. Keep
the seat back upright.[3]

 Don't cross your legs! This reduces the space at the front of the pelvis, and
opens it up at the back. For good positioning, the baby needs to have lots of
space at the front

 Don't put your feet up! Lying back with your feet up encourages posterior
presentation.
 Sleep on your side, not on your back.

 Avoid deep squatting, which opens up the pelvis and encourages the baby to
move down, until you know he/she is the right way round. Jean Sutton
recommends squatting on a low stool instead, and keeping your spine
upright, not leaning forwards.
  Swimming with your belly downwards is said to be very good for
positioning babies [1] - not backstroke, but lots of breaststroke and front
crawl. Breaststroke in particular is thought to help with good positioning,
because all those leg movements help open your pelvis and settle the baby
downwards. [3]

 A Birth Ball can encourage good positioning, both before and during labour.
See Birth Balls article on the MomCare website for more details.

 Various exercises done on all fours can help, eg wiggling your hips from
side to side, or arching your back like a cat, followed by dropping the spine
down. This is described in more detail in an article on www.wellmother.org
- 'Exercise for relieving backache' by Suzanne Yates.

 More ideas from a Shiatsu teacher specialising in pregnancy care: Shiatsu

and Optimum Foetal Positioning, again by Suzanne Yates.

(Nothing to do with baby positioning, but... if you're swimming, make sure you
have goggles so you can swim in a good position, with your face partially or
wholly in the water as you dip down. Doing breaststroke with your neck craned,
holding your face out of the water, is bad for your neck and back at any time, let
alone in pregnancy when ligaments are loose.)
 If your baby is already posterior...
First of all, don't panic! Most posterior babies will turn in labour, but read on
to find ways of helping him or her turn before.

When your baby is in a posterior position, you can try to stop him/her from
descending lower. You want to avoid the baby engaging in the pelvis in this
position, while you work on encouraging him to turn around. Jean Sutton says that
most babies take a couple of days to turn around when the mother is working hard
on positioning.

 Avoid deep squatting

 Use the 'knee to chest' position. When on hands and knees, stick your
bottom (butt) in the air, to tip the baby back up out of your pelvis so that
there is more room for him to turn around.
 Sway your hips while on hands and knees
 Crawl around on hands and knees. A token 5 minutes on hands and knees is
unlikely to do the trick - you need to keep working at this until your baby
turns. Try crawling around the carpet for half an hour - while watching TV
or listening to music. It is good exercise as well as good for the baby's
position!
 Don't put your feet up! Lying back with your feet up encourages posterior
presentation.
 Swim belly-down, but avoid kicking with breaststroke legs as this
movement is said to encourage the baby to descend in the pelvis [3]. You
can still swim breaststroke, but simply kick with straight legs instead of
"frogs' legs".
 Try sleeping on your tummy, using lots of pillows and cushions for support.

The Kneeler-Rocker

If your baby is persistently posterior, Jean Sutton recommends using a special

kneeler-rocker chair for the last few weeks of pregnancy. This is like a kneeling
stool, which sits you in a helpful upright position with knees lower than your chest,
but it has rockers underneath it. The combination of upright posture and rocking
movement encourages the baby to rotate.

In the UK, you can hire a kneeler-rocker from Jill Sutton (Jean's daughter-in-law)
on 020 8890 8298 - cost £40 for a four-week hire period in 2000.

Elsewhere, try midwifery or doula organisations, or specialist back chair shops

(which sometimes sell kneeler rockers, although they probably have not heard of
them used specifically for this purpose). For example, Norwegian furniture
company Stokke make a kneeler-rocker designed to encourage good posture at
your PC or desk. It is not constructed specifically with pregnant women in mind, as
Jean Sutton's rocker is, but would still be useful. You can see their Stokke Variable
Balans online, and get details of suppliers. In the UK, you can buy this chair
from Back In Action.

When your baby turns to an anterior position, you can encourage him to descend
further into the pelvis - by walking around upright, massaging your bump
downwards, deep squatting, and swimming - and now you can use lots of
breaststroke "frogs' legs" kicking.[3]
 If your baby is posterior when you are in labour:
Remember, most posterior babies will turn during labour (87% according to
Gardberg study - see refs), but even if yours doesn't, a baby can still be born
vaginally in the posterior position - "face to pubes" - and this can happen at a
homebirth. Sometimes a posterior labour can make things just too tough, but
it can work out.

You may try your hardest to get your baby into a good position, but he may be
determined to stay the way he is - if so, there are things you can do in labour to
help a posterior baby to be born.

The majority of babies who experience a posterior labour, actually start labour in
an ideal position, and then turn posterior while you are in labour. Gardberg et al
found that 68% of posterior babies took this route. This seems very unfair - but if it
happens, these tips should still help.

These movements can help the baby wriggle through your pelvis, past the ischial
spines inside it, by altering the level of your hips. They are also helpful if the baby
is anterior but has a presentation problem, eg his head is tipped to one side
(asynclitic).

 In early labour, walk up stairs - sideways if you need to.

 Rock from side to side
 March or 'tread' on the spot
 Step on and off a small stool
 Climb in and out of a birth pool [3]
 The positions listed below may also help.

For the second stage:

 Use kneeling or all-fours positions. Kneeling on one knee can help.

 Supported squatting in second stage, but the mother must be lifted quite high
up; her bottom should be at least 45cm (18 inches) off the floor.
 Birth stool seats should be at least 45cm (18 inches) from the floor.
 Avoid lying on your back, semi-reclining, sitting or semi-sitting. These
positions all reduce the available space for the baby to turn. Lying on the
side is OK.
 What about sleeping on your back?
Sometimes women are concerned that sleeping on one's back is dangerous in
pregnancy, either because it may deprive the baby of oxygen, or because it may
encourage posterior presentation. Here are some comments from independent
midwife, Virginia Howes, of Kent Midwifery Practice:

One thing I do come across often is the idea that sleeping on your back is bad when
you are pregnant. Women should sleep in whatever way they are comfortable. The
important thing is a good night's sleep and women do not need to feel guilty when
they wake up on their back. This is a myth that has come about through a
misunderstanding of the facts and unfortunately is constantly perpetuated.

When epidurals were first introduced into childbirth the dose of drugs used was
considerably higher than it is now and the paralysing block very dense. Women
were being left on their back and unable to move even if they wanted to. The heavy
uterus would press onto the big oxygen-carrying blood vessels in the lower back
and cause a decrease in a woman´s oxygen levels and consequently the oxygen
reaching the baby. Thus came about the information that women should not be left
to lie on their backs when they have an epidural. Quite correct information for that
group of women.

However if a woman without an epidural lies on her back and her oxygen levels
are compromised, the first thing that will happen is she will become short of
breath. That will happen prior to the baby being compromised and of course the
woman will move off of her back or wake up and move.

Virginia Howes - Kent Midwifery Practice

 Is there any proof that this works?
Midwives and mothers who have learned about, and used, Optimal Foetal
Positioning techniques are convinced that it works. There is a wealth
of anecdotal evidence in favour of it. However, there have not been many trials or
studies on the subject so far, because they would be extremely difficult to organise.
Practising techniques to turn a posterior baby can take a lot of commitment on the
part of the mother, which could not be assumed in a randomised trial. There would
also be ethical problems with a trial - would mothers in the control group be told
not to adopt upright or forward-leaning postures? Or would they simply not be told
that taking care with their posture could lead to an easier labour?

Stremler et al study on hands-and-knees in OP labours

The most recent research on using hands-and-knees position in labour, where the
baby is known to be OP, has supported OFP theory. Stremler and
colleagues confirmed that babies were OP by ultrasound, then asked the women
concerned to spend at least 30 minutes out of an hour on hands-and-knees while
labouring. The baby's position was checked after an hour. Twice as many babies
had turned OA at the end of that hour in the hands-and-knees group, as in the
control group. However, because of the small numbers involved this did not reach
statistical significance. I think most of us would be prepared to take a chance on
that! What did reach statistical significance, however, was the women's experience
of back pain; the hands-and-knees group experienced significant reductions in
persistent back pain than the control group.

BMJ article on hands-and-knees in late pregnancy

A study published in the British Medical Journal January 2004 found that just
going on hands-and-knees in late pregnancy (but not labour) was not enough to
stop you having a posterior baby at birth. This is probably because many babies
(approx two thirds) who are OP in labour, have only turned OP during labour.
Therefore it's not what you do before labour which is important, so much as what
you do during labour. The reference is:

Azar Kariminia, Marie E Chamberlain, John Keogh, and Agnes Shea

Randomised controlled trial of effect of hands and knees posturing on incidence of
occiput posterior position at birth
BMJ, Jan 2004; 10.1136/bmj.37942.594456.44

The Kariminia et al study (above) did not really look at OFP techniques in the way
a committed woman might practise them - women in the study were asked to go on
hands and knees and do pelvic rocks for just 10 minutes, twice a day. It did not
look at whether babies were posterior or anterior at the start of labour - only at
their position at the end of labour. It did not look at the position or movements of
the mothers in labour, and the study didn't include any advice to women on labour
positioning. Finally, it did not note whether the babies who were OP at the end of
labour, had started labour OP, or had started labour OA and had turned OP during
labour. So what it tells us is that a token, brief attempt at OFP techniques from 37
weeks onwards, is not on its own going to do very much for the average woman. I
don't think many OFP supporters would disagree with that! It's a great shame that
the study did not look at the positions the babies were in at the start of labour, or
the positions of the mothers during labour. I imagine that the briefness of the OFP
exercises was probably because the motivation came from the researchers, not the
mothers; if they'd asked women to commit to a more comprehensive exercise and
positioning package, fewer women would have complied.

There is an interesting letter from three UK midwives criticising the study, on the
BMJ website. They say:

"The use of hands and knees posturing, otherwise referred to as the 'all fours
posture', is widely used by midwives. It is surprising that Kariminia et al (2004)
refer to it as an intervention based on personal belief (1). The use of the all fours
posture has long been supported by the laws of physics and physiology (2). The
law of gravity states that all objects are drawn towards the earth, and that the
acceleration of movement is dependent on the mass and the availability of space. If
this is applied to the fetus where the mother has adopted the all fours posture the
heaviest poles of the fetus (the trunk and the occiput) would be drawn towards the
earth, and into an anterior position. Such movement would be hindered only in two
cases; [1] if the mass (the fetus) was not heavy enough to exert a force of
acceleration or [2] if there was no available space into which the mass (fetus) could
move. It appears that such principles were not considered by the authors for the
intervention used in their study. Firstly, by implementing the intervention at 37
weeks, the availability of space was restricted. Midwifery practice advocates such
intervention at 34-35 weeks when more space is available. Secondly the
intervention was not implemented when the fetus was in an active state, which
would have encouraged further movement of an already moving object. Another
very important principle that was neglected related to the specific nature of the
associated rocking with the all-fours posture. If 'rocking' equates to swaying of the
pelvis from side to side this would exert only a frictional force which, solely,
would not be of great benefit. If, however, posturing included movement of the
maternal trunk backwards and forwards whilst on all fours this would both increase
the available space at the pelvic inlet and along with gravitational and buoyancy
forces will encourage frictional movement (3). As the mother moves her trunk
forward, her spine is encouraged to move away whilst the maternal symphasis
drops down, thus increasing the available space in the pelvic inlet and allowing the
fetus more room to rotate to an anterior position.
 If the study intervention did not consider any of these vital principles, it is hardly
surprising that the result of the trial was negative. At best what the authors can
claim is that their particular form of maternal posturing was both ineffective at
decreasing the incidence of occiput-posterior position at birth and painful to the
study participants. It cannot by any means be concluded that appropriate hands and
knees exercise should be discontinued as a way of changing fetal position. No
doubt further research is required, but it would be a mistake to use this study alone
as a rationale for dismissing maternal posturing as a potentially effective means of
changing fetal position. "

Aishah Bibi, Registered Midwife

Bernadette Earley, Registered Midwife
Sara Webb, Registered Midwife

Birmingham Women's Healthcare NHS Trust

References

(1) Kariminia et al (2004) Randomised controlled trial of effect of hands and knees
posturing on incidence of occiput posterior position at birth. British Medical
Journal 2004(328) pp.490-493

(2) Barnum C G (1915) The effect of gravitation on the presentation and position
of the fetus. Journal of the American Medical Association. 64 pp.498-502 (3) Sears
F W & Zemansky M W (1960) College Physics (3rd Edition) Addison-Wesley
Publishing Company, Reading, Mass.

There has been one other small study [4] which looked at the short-term effects of
mothers adopting a hands-and-knees position, compared to sitting, when their baby
was in a lateral or posterior position. Mothers were asked to go on hands and
knees, or to sit, for a short period of time, and the position of the baby was noted
ten minutes afterwards. The study found that babies were far less likely to remain
posterior after mothers had been on hands and knees.

This could be very useful for women whose babies are in the posterior position
when they go into labour. However, since the babies' positions were only assessed
for ten minutes after one session on hands and knees, this study doesn't tell us very
much about the longer-term effects of alterations in the mother's posture. You can
read the abstract in the Cochrane Pregnancy and Childbirth Database.

Some good evidence for the effectiveness of the theory comes from its author's
own practice. When Jean Sutton was appointed Principal Nurse Midwife at a
maternity unit in New Zealand, she emphasised antenatal education on foetal
positioning. The transfer rate from maternity unit to hospital fell from 30% to 5 %
and the forceps delivery rate fell from 3-4 per month, to 2-4 per year, over a period
of several years [2].

Perhaps the most valuable aspect of OFP theory is that it gives you a set of tools to
use if you find your baby has turned OP during labour. Remember that many
babies are OA at the start of labour, but may turn OP as the labour progresses -
thought to be more likely if the mother is lying back or sitting back, and if she has
an epidural. If you can move, you can do something about it.
 Is it worth the effort and the worry?
My first baby, Lee, kept trying to settle in a posterior position because his placenta
was attached to the front wall of the uterus (anterior placenta). Babies generally
tend to face the placenta, and most placentae implant on the back wall of the uterus
(posterior placenta). So if your baby's placenta is on the front wall then you will
need to be extra-careful about positioning as the baby's natural tendency may be to
settle in a posterior position. This has long been noted amongst midwives, and has
now been confirmed by research (eg Gardberg [6].)

I would feel Lee turning towards my front as he got larger, and every time I would
go down on all fours, rock my hips and wiggle around until I felt his back towards
my belly button. Then I'd stand up and walk around to settle him there, massaging
him downwards. Despite his best efforts to turn around, I won!! And had a 9 hour,
straightforward, completely natural labour to produce a 9lb 6oz (4,250g) first
baby... I was told that if he'd remained in a posterior position then I would
probably have ended up a very hard labour, and probably major intervention and
perhaps a caesarean given his size.

Certainly OFP made me feel that there was something positive I could do before
labour to help things go well, rather than crossing my fingers and hoping I was
lucky. But, as most OP babies start off labour in the perfect position anyway, is it
really worth the effort? Only you can say. If your baby is not OP in late pregnancy,
there's limited point in spending your last weeks bouncing on a birthing ball and
becoming anxious. For most labours, it's what happens when you are in
labour which is most important.

If your baby does appear to be in a posterior position, you will probably need to
put considerable effort into persuading him to move around. It is no use spending
five minutes on your hands and knees every now and then, and then saying
"I tried to turn him, but it didn't work...". Optimum Foetal Positioning should be
a lifestyle for you, for those last few weeks of pregnancy, not just an occasional
distraction. Adopting a 'good' position now and then will not make much
difference if you are in 'bad' positions for the majority of the time. A 'good'
position is not a magic cure, a pill that you can take to turn your baby. The only
person who can get your baby into a good position is you, and
unfortunately, you are going to have to do the work to make it happen!

It may be that your baby is going to stay 'sunnyside up' and will just refuse to turn;
perhaps that's the way he/she needs to be. However, it can't hurt to try to get the
baby to turn. If you doend up having a posterior labour (and they're not all
dreadful, but many are harder than they would otherwise be), at least you'll know
you did all you could to make things easier for you and the baby.
 On the other hand, it is important to note that some babies will turn to a posterior
presentation in labour, despite having been apparently ideally positioned
beforehand. You can live and breathe optimum foetal positioning in your last
trimester, and still have a posterior baby. Sometimes things really aren't fair...only
you can decide how much effort it is worth investing into this antenatally. It's in
labour that OFP is really important.

Midwife Virginia Howes, of the Kent Midwifery Practice, says:

In my opinion women know a lot about optimal fetal positioning and are keen to
try and optimise the baby's position in preparation for birth. I do find however that
some women get really worried about it and that on occasion gives me a dilemma
about discussing it with them as I do not want to worry them unduly.

MOST babies know exactly what a good position is for them and adopt it. Second
time or subsequent mothers need to consider it even less as most of their babies
either turn prior to or during labour or even stay in the same position and birth
perfectly fine.

It is, in my experience, a first-time rare occurrence that babies remain in the

occipital posterior position. This may also be however due to the fact that most of
the women I care for labour and/or give birth at home, and do so in upright
positions, not laying flat on a bed. I think if women can remain active till D-day
and in early labour, it is a good thing. Where possible, without exhausting
themselves, my advice is to keep active with plenty of walking, working, dancing,
yoga etc. Also do not put on too much weight as bigger babies appear to get into
the occipital posterior position more often than smaller ones. We do not have much
in the way of actual research evidence to support the ideas about optimal fetal
positioning but tacit and anecdotal evidence from midwives and other active birth
experts such as Jean Sutton is valuable.

Virginia Howes - Kent Midwifery Practice

 Birth Stories - babies in awkward positions
Julia N had a wonderfully straightforward home waterbirth with her first baby,
despite him turning OP halfway through her labour - he righted himself before the
end.

Sam RK was dreading a long labour and wondering what pain relief she'd need,
when she found out that her first baby was back-to-back. But things progressed
much faster than she expected: "The pool had three inches of water in it, the 2nd
midwife was still on her way with the entonox and I had a baby!"

Rachael K planned a home birth for her first baby; her waters broke at home, but
she spent several days in latent labour before her baby showed signs of distress,
and Rachael changed her plans to a hospital birth. Baby Matilda was a brow
presentation, and was born by emergency c-section.

Naomi W had her 7th baby at home, very quickly, with just two of her other
children there for company. Her midwife and husband arrived shortly afterwards to
find a very competent mother with a healthy baby. In case this all sounds a little
too easy, Naomi had endured the traditional lot of mothers of large families -
seemingly endless 'Is it? Isn't it?' prelabour and weeks of irregular contractions
which didn't appear to be doing anything, when her baby was in the OP position.

Inger developed pre-eclampsia and transferred to hospital for induction. Her baby
was OP and was turned by forceps at full dilation, after which she managed to push
him out herself.

Gina's first baby turned from ROA before labour to OP. She transferred to hospital
when he passed meconium, and her story shows that while OP can make a first
labour tougher, it doesn't have to end with an assisted delivery : "Incredibly, I had
managed a posterior labour with a synto drip with just the aid of a TENS machine
and my yoga breathing! I don't remember having any particular pain in my back,
perhaps because of the TENS, although I couldn't stand to be on my back at all. "

Rachel Vincent's third baby was in a persistent OP presentation, born facing

upwards; despite this, Rachel managed to deliver him without even a graze.

Tina Redford had her third baby at home. He was in the occiput posterior position,
and was much larger than Tina's first two.

Gemma planned a homebirth for her first baby, but her painful, posterior labour
didn't fully establish, and she transferred to hospital for help - which took a while
to be given..
 Judith's baby was not in an awkward position at all, but I'm including her story
here because she describes a number of active labouring positions and movements
which her midwife recommended to bring her baby's head down, and which could
be useful if you were trying to persuade a baby out of a slight malpresentation.

Caroline Brown's first baby was OP in labour but Caroline still managed using
only TENS and water for pain relief.

Charlie Paris's first baby was persistent occiput posterior, born face-up, and she
still managed to have a straightforward homebirth.

Jane was expecting a two-hour labour for her seventh baby, but instead had a two-
DAY stop-start labour, because he was posterior.

Victoria's fifth baby was born at home after a very tough labour. Esmé was not
only posterior, but with both hands by her face.

Leighan's third baby was a face presentation - this happens in only around 1 in 500
births, and I'm not aware of anything you can do to prevent it.

George's first baby, Jemima, moved from right anterior to left anterior in the
second stage of labour. George used OFP techniques because babies in the right
anterior position often move to posterior in labour, and she managed to avoid this.

Sarah Mitchell's first baby, Amber, was born at home. Amber's head was asynclitic
(tilted to one side).

Kiara's first baby, Ben, managed not only to turn himself posterior - probably
during labour - but his head was also deflexed and asynclitic, ie tilted up and to the
side. He was born by caesarean section after three hours of pushing could not
budge him.

Caroline Creasey's fourth baby, Mia, was born at home in water. Mia was in the
posterior position and stayed that way throughout labour - she was born face-up.

Deborah Black's third baby, Kyle, was born at home, after a lot of effort to turn
him from a posterior position in the second stage.

Sarah Sadler's first baby, Kirsty, was born in hospital after transferring from home
because of a long second stage. Kirsty had decided to start labour in the posterior
position...

Karen Fairweather's first baby, Emily, was born in hospital with the help of forceps
after she transferred from a planned home birth. Emily was OP in the second stage
of labour.
Suzanne Williams's first baby, Kira, was asynclitic (head tilted slightly to one side)
and had her hands up by her face, so it was quite an achievement for Suzanne to
give birth to her without assistance. Despite this, Kira was born at home, only five
hours after Suzanne felt her first contraction.

Steph Amor's first baby was posterior, and she used OFP techniques in her second
pregnancy to try to avoid a repeat. Everything went smoothly...

Kate Wood transferred to hospital because her midwives were worried about the
progress of her posterior labour. Kate still managed a natural birth in hospital.

Jo Robertson transferred to hospital because of slow progress in a posterior labour,

prolonged rupture of membranes, and meconium in the waters. Her baby turned
during labour, and Jo had a very positive birth in hospital.

Rachel tried very hard to have her first baby, Freya, at home, but after labouring
for nearly two days, she transferred to hospital. After that marathon, she gave birth
soon after arriving in hospital, with the assistance of a ventouse. Midwives
commented that Freya was in a 'funny position' and Rachel suspects that she was
posterior.

More to come later ... I would not want to give the impression that the majority of
OP labours end in transfer to hospital - it's just easier to find birth stories of OP
labours amongst those which ended in transfer.

Books to read:
'Understanding and Teaching Optimal Foetal Positioning' by Jean Sutton and
Pauline Scott, in New Zealand: Birth Concepts, 1995.
This book is out of print but has been replaced by:

How will I be born - 2007 edition by Jean Sutton. Available from Rob Sutton at
182 Cygnet Ave, Feltham TW14 0DR UNITED KINGDOM for an inclusive cost
of £10.00.

Pauline Scott's new book Sit Up and Take Notice: Positioning for a Better
Birth was published in Australia in 2003 and copies occasionally come up in the
UK via Amazon.

More information online:

Posterior Babies - what mothers can do - from the UK's Association for
Improvements in the Maternity Services (AIMS)
www.aims.org.uk/posterior.htm
 Article on posterior babies, with photos of a pregnant mother's tummy when
carrying a posterior baby, and tips on how to spot a posterior
presentation: www.mother-care.ca/pos_sym.htm

Posterior Presentation - A Pain in the Back! Article by midwife Valerie el Halta on

posterior babies and how to turn them anterior for faster, easier
labours: www.mother-care.ca/pos_pain.htm

UK Midwife Archives page on presentation, from the Association of Radical

Midwives (www.midwifery.org.uk)

The Midwife Archives on the gentlebirth.org website have an amazing collection

of wisdom and experience on just about every subject related to pregnancy and
birth. The pages on positioning start at www.gentlebirth.org/archives/position.html

Article on positioning and how to improve it, with good diagrams of baby in womb
and pictures of exercises for mum: www.cefcares.org/fetal/position.htm

By Shiatsu practitioner Suzanne Yates (who also runs courses for parents and
professionals in Bristol, UK):
'Exercise for relieving backache'
Shiatsu and Optimum Foetal Positioning, originally published in 'Practising
Midwife'.

'The Dreaded Persistent Occiput Posterior' on www.midwifeinfo.com

References:
All data and recommendations in this article are from [1] below unless stated
otherwise.

[1] 'Understanding and Teaching Optimal Foetal Positioning' by Jean Sutton and
Pauline Scott, in New Zealand: Birth Concepts, 1995.
Available in the UK from Jean Sutton's daughter-in-law, Jill Sutton, for £6 sterling
- please send cheque made out to J Sutton with A5 or larger envelope, and 41p
stamp, to: 95 Beech Rd, Feltham, TW14 8AJ.
Available online from NCT Maternity Sales.

[2] Modern Midwife , January 1997 Vol 7 No 1, article by Mary Nolan

[3] Recommendations from other sources, including antenatal classes I have

attended, and discussions with midwives and antenatal teachers, which are not
specified in Jean Sutton's 'Optimum Foetal Positioning'.
 [4] Hofmeyr GJ, Kulier R. Hands/knees posture in late pregnancy or labour for
fetal malposition (lateral or posterior) (Cochrane Review). In: The Cochrane
Library, Issue 2, 2000

[5] Gardberg et al (1998)

Obstet Gynecol. 1998 May;91(5 Pt 1):746-9.

Intrapartum sonography and persistent occiput posterior position: a study of 408
deliveries.

Gardberg M, Laakkonen E, Salevaara M.

Department of Obstetrics and Gynecology, Vaasa Central Hospital, Finland.

OBJECTIVE: To use intrapartum sonography as a tool to investigate the

development of the persistent occiput posterior position during labor, as well as to
identify parameters correlating with the outcome of labor.
METHODS: A prospective study of 408 women in labor after 37 weeks' gestation
with a singleton fetus in a vertex position using sonography at the onset of labor
was performed. Fetal position, placental location, and maternal BMI (body mass
index) were recorded. Outcome of labor was monitored for all relevant
parameters.
RESULTS: Most (68%) of persistent occiput posterior positions develop through a
malrotation during labor from an initially occipitoanterior position. Only 32% of
persistent cases were occipitoposterior (dorsoposterior) at the onset of labor;
operative interventions were required in 87.5% of these. Of the 61 (15%)
occipitoposterior positions at the onset of labor, 53 (87%) rotated into an occiput
anterior position. Persistent occiput posterior position was more common in the
initially occipitoposterior group (P < 0.01, Fisher exact test), and posterior
placental locations were fewer (z test, P = 0.05). Also, operative deliveries were
more common in the group remaining occipitoposterior throughout labor (P < .01,
Fisher exact test). A higher maternal BMI correlated with neonatal weight (P < .01,
Pearson correlation), an increase in operative deliveries (P = .032, Pearson
correlation), lower Apgar scores at 1 minute (P = .02, Spearman correlation), and
increase in posterior placental locations (P = .037, two-tailed t test).
CONCLUSION: In most cases, persistent occiput posterior position develops
through a malrotation and only in a little more than one-third of cases through
absence of rotation from an initially occipitoposterior position. Higher maternal
BMI correlates with higher fetal weight, increased operative deliveries, lower
Apgar scores at 1 minute, and posterior placental locations. Intrapartum
sonography proved to be useful in investigating the development of the persistent
occipitoposterior position.

PMID: 9572223 [PubMed - indexed for MEDLINE]

[6] Gardberg (1994)

 5: Acta Obstet Gynecol Scand. 1994 Feb;73(2):151-2.

Anterior placental location predisposes for occiput posterior presentation near

term.

Gardberg M, Tuppurainen M.

Department of Obstetrics and Gynecology, Vaasa Central Hospital, Finland.

325 sonographies were performed in singleton pregnancies past 36 weeks with the
fetus in a vertex position in order to examine a possible association between
placental localization and occiput posterior presentation (OP). OP was found in
11.6% of all cases. The distribution of the placental locations in the OP group
differed significantly from the occiput anterior (OA) group. Also, an anterior
placental location was seen significantly more often in the OP group.

PMID: 8116354 [PubMed - indexed for MEDLINE]

[7] Stremler et al (2005)

Birth. 2005 Dec;32(4):243-51.

Randomized controlled trial of hands-and-knees positioning for occipitoposterior

position in labor.

Stremler R, Hodnett E, Petryshen P, Stevens B, Weston J, Willan AR.

The Hospital for Sick Children, Toronto, Ontario, Canada.

BACKGROUND: Hands-and-knees positioning during labor has been

recommended on the theory that gravity and buoyancy may promote fetal head
rotation to the anterior position and reduce persistent back pain. A Cochrane
review found insufficient evidence to support the effectiveness of this intervention
during labor. The purpose of this study was to evaluate the effect of maternal
hands-and-knees positioning on fetal head rotation from occipitoposterior to
occipitoanterior position, persistent back pain, and other perinatal outcomes.
METHODS: Thirteen labor units in university-affiliated hospitals participated in
this multicenter randomized, controlled trial. Study participants were 147 women
laboring with a fetus at >or=37 weeks' gestation and confirmed by ultrasound to be
in occipitoposterior position. Seventy women were randomized to the intervention
group (hands-and-knees positioning for at least 30 minutes over a 1-hour period
during labor) and 77 to the control group (no hands-and-knees positioning). The
primary outcome was occipitoanterior position determined by ultrasound following
the 1-hour study period and the secondary outcome was persistent back pain. Other
outcomes included operative delivery, fetal head position at delivery, perineal
trauma, Apgar scores, length of labor, and women's views with respect to
 positioning.
RESULTS: Women randomized to the intervention group had significant
reductions in persistent back pain. Eleven women (16%) allocated to use hands-
and-knees positioning had fetal heads in occipitoanterior position following the 1-
hour study period compared with 5 (7%) in the control group (relative risk 2.4;
95% CI 0.88-6.62; number needed to treat 11). Trends toward benefit for the
intervention group were seen for several other outcomes, including operative
delivery, fetal head position at delivery, 1-minute Apgar scores, and time to
delivery.
CONCLUSIONS: Maternal hands-and-knees positioning during labor with a fetus
in occipitoposterior position reduces persistent back pain and is acceptable to
laboring women. Given this evidence, hands-and-knees positioning should be
offered to women laboring with a fetus in occipitoposterior position in the first
stage of labor to reduce persistent back pain. Although this study demonstrates
trends toward improved birth outcomes, further trials are needed to determine if
hands-and-knees positioning promotes fetal head rotation to occipitoanterior and
reduces operative delivery.

Publication Types:
Multicenter Study
Randomized Controlled Trial

PMID: 16336365 [PubMed - indexed for MEDLINE]

[8] Cochrane database review of hands-and-knees in late pregnancy

: Cochrane Database Syst Rev. 2005 Apr 18;(2):CD001063. Related Articles,

Links

Update of:
Cochrane Database Syst Rev. 2000;(2):CD001063.

Hands and knees posture in late pregnancy or labour for fetal malposition (lateral
or posterior).

Hofmeyr GJ, Kulier R.

University of the Witwatersrand, University of Fort Hare, Eastern Cape

Department of Health, Frere and Cecilia Makiwane Hospitals, Private Bag X 9047,
East London, Eastern Cape, South Africa, 5200. gjh@global.co.za

BACKGROUND: Lateral and posterior position of the baby's head (the back of the
baby's head facing to the side or the mother's back) may be associated with more
painful, prolonged or obstructed labour and difficult delivery. It is possible that
 certain positions adopted by the mother may influence the baby's position.
OBJECTIVES: The objective of this review is to assess the effects of adopting a
hands and knees maternal posture in late pregnancy or during labour when the
presenting part of the fetus is in a lateral or posterior position, compared with no
intervention. SEARCH STRATEGY: We searched the Cochrane Pregnancy and
Childbirth Group Trials Register (November 2004) and the Cochrane Central
Register of Controlled Trials (The Cochrane Library, Issue 4, 2004). SELECTION
CRITERIA: Randomised trials of hands and knees maternal posture compared to
other postures or controls.
DATA COLLECTION AND ANALYSIS: Both review authors assessed trial
eligibility and quality.
MAIN RESULTS: Two trials of hands and knees posture during pregnancy were
included. In one trial involving 100 women, four different postures (four groups of
20 women) were combined for the comparison with the control group of 20
women. Lateral or posterior position of the presenting part of the fetus was less
likely to persist following 10 minutes in the hands and knees position compared to
a sitting position (one trial, 100 women, relative risk (RR) 0.25, 95% confidence
interval (CI) 0.17 to 0.37). In a second trial including 2547 women, advice to
assume the hands and knees posture for 10 minutes twice daily in the last weeks of
pregnancy had no effect on the baby's position at delivery or any of the other
pregnancy outcomes measured. No trials of hands and knees posture during labour
were included.
AUTHORS' CONCLUSIONS: Use of hands and knees position for 10 minutes
twice daily to correct occipitoposterior position of the fetus in late pregnancy
cannot be recommended as an intervention. This is not to suggest that women
should not adopt this position if they find it comfortable. The use of this position
during labour has not been addressed in this review. In view of the promising
short-term effects of the technique and its simplicity, further trials are justified to
determine whether encouraging the use of hands and knees posture during rather
than before labour, has any effect on substantive outcomes.